Subjective — ask

• The support system — who helps, with what, and how reliably; the patient's sense of its adequacy.
• The caregiver situation — the caregiver's capacity, competence, willingness, health, and stress.
• The patient's coping with and adjustment to the illness and the care demands.
• Social-determinant stressors — housing, food, money, transportation, and utilities.
• Unmet needs, financial barriers to the plan, isolation, and advance-care-planning wishes.